A Focused Soap Note 

A mother brings her 14-year-old daughter to the clinic because of a persistent facial rash that has been present for 3 to 4 weeks. The child is restless at night and scratches in her sleep. She is otherwise healthy. Physical examination reveals a well-nourished, healthy-appearing girl with dry, red, scaly areas on the cheeks, chin, chest, and around the mouth, as well as on the extensor surfaces of her extremities. The areas on the cheeks have a plaque-like, weepy appearance with papules. The remainder of the child’s examination is normal. Atopic Dermatitis

· Chief Complaint: Did I state briefly in the patient’s own words

· History of present illness: Did I write a paragraph in the order of the 7 attributes & did I put the 7 attributes in a concise list in the chart (OLD CART-if you don’t know it, please look it up)

· Medications: did I list each medication and reason.

· Allergies: Did I include specific reactions to medications, foods, and insects, environmental?

· Past Medical History (PMH): Did I list all the patient Illnesses, hospitalizations? Did I Include childhood illnesses

· Past Surgical History (PSH): Did I list the dates, indications and types of operations?

· OB/GYN History: (if applicable) Obstetric history, menstrual history, methods of contraception and sexual function.

· Personal/Social History: Tobacco use, Alcohol use, Drug use, risky sexual behavior. Patient’s interests, ADL’s IADL’s if applicable. Exercise, eating habits. Pediatrics: school status, parental smoking hx, birth history, school/daycare etc

· Immunizations: Did I include Last Tdap, Flu, pneumonia, etc. Pediatrics- (per pediatric schedule for age) HPV if applicable

· Family History: Did I list for Parents, Grandparents, siblings, children?

· Review of Systems (SUBJECTIVE DATA): Did I include the systems related to my Chief Complaint and chronic conditions? Did I type detailed description? I did NOT use WNL. I was specific in my descriptions (see health assessment textbook). Did I remember this is what the patient says and not what I observed? Did I include the cardiovascular and respiratory system regardless of chief complaint?